Provider First Line Business Practice Location Address:
4215 SPRING ST
Provider Second Line Business Practice Location Address:
314C
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91941-7965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-754-3725
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2005